Inspection·November 18, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent staff-to-resident physical and verbal abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of the 3. The findings include:The facility's Final Report to the local health department (date submitted not provided in report) showed, on 11/8/25 at 4:45 PM, V4 and V5 Certified Nursing Assistants (CNAs) entered R1's room, an incontinent resident, to provide cares.and get him ready for dinner. [R1] is resistant often to care, including yelling out when being provided peri care. The report showed V4 indicated V5 became frustrated with [R1's] reluctance of care and quickly pulled the blankets and sheet off him. [R1] then reacted negatively by yelling, again. [V5] then pinched the resident's nose and told [R1] to ‘shut up and be quiet' and ‘shut the f*** up.' The report showed, Allegations made by [V4] against [V5] are founded. [V5] will not be returning to work at [the facility].The facility's investigation included V4's Employee Statement (handwritten note signed by V4 on 11/8/25) which showed, .We (V4 and V5) walked into his room and right off the bat [R1] was a little irritated and did not want to get up for dinner. We told him that he did have to get up because he needs to eat. [V5] then proceeds to throw the blankets off of [R1] and [R1] grunts because she did it aggressively and she then tells [R1] to ‘Shut up. Be quiet.' We start to change him and get his pants on and he's still grunting, kind of screeching at this point so I tell [R1] ‘I'm sorry. We're not trying to hurt you, just get you changed.' [V5] goes on to say ‘shut the f*** up!' and grabs his nose hard and twists it and pulls on his nose. After we are done getting him up, I immediately go to tell [V10] and [V1] about the situation. The investigation showed V5 had received abuse training. On 11/18/25 at 10:10 AM, R1 was alert but pleasantly confused. R1 did not recall the incident on 11/8/25. R1 began speaking about a man helping him downtown. R1 had no injuries to his nose or face. On 11/18/25 at 11:19 AM, V4 CNA stated she has worked at the facility for a year, and she has been a CNA for two years. V4 stated she had only worked with V5 CNA one other day prior to 11/8/25. V4 said on that training day (V5 was a new employee to the facility) V5 was telling residents to be quiet and she doesn't want to hear them. V4 stated these statements were reported to a supervisor. V4 stated the next day she worked with V5 was on the afternoon of 11/8/25. V4 stated on that afternoon she went to assist V5 with getting R1 ready for supper. V4 stated R1 moans and groans while the staff provide care and get him up. V4 stated all of the staff are aware of R1's behaviors during care and she believes it is due to his catheter, which irritates him. V4 stated V5 kept telling R1 to be quiet and to shut the f**** up. V4 stated, She did actually use that word. I'm not a confrontational person. I was very shocked when she said that. I should have stopped her at that time. V4 stated, after that statement they continued to get R1 ready and transfer him out of bed with a mechanical lift. V4 said V5 was operating the mechanical lift, R1 was continuing to moan, V5 reached around the mechanical lift and grabbed his nose, twisted it, pulled it, and told him to be quiet. V4 said, there is no question (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146114 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)